Thursday, 5 February 2009

I go up to the surgical assessment unit (SAU) in search of Bill. I’ve not yet met Bill and I know very little about him. I know his name, his age and that in order to survive, he’s going to need an operation and, as the anaesthetist on call, it’s my job to try and guide him through it. Despite the fact that Bill and I have never met, as I walk up the stairs, I have grave concerns for his welfare. You see, Bill is 94 years old and the surgeon has told me that he has kidney, heart and respiratory problems. This means that Bill’s future lies precariously in the balance.

I arrive on SAU and it’s packed. I can’t see Bill’s name on the whiteboard so I ask one of the nurses about his whereabouts. The young staff nurse flashes me a smile and shows me where Bill medical records are then points me in his direction, her name badge reads “Emma.” I make a mental note of it, thank her and go and introduce myself to Bill.

The elderly gentleman is lying in his bed with a lady, who introduces herself as his daughter, by his side. I say hello and Bill tells me he’s glad to meet me whilst apologising for not having his false teeth in. I tell him not to concern himself about it and ask him about himself.

I’m learning that part of the art of anaesthesia is trying to build a picture in my own mind about what is likely to happen to my patients both during and after their operation. From speaking to them, examining and looking at the results of a few simple tests, I can get a picture of what the person in front of me is likely to look like one, two, three, seven, ten days after their operation. It’s almost like trying to gaze into a crystal ball and if what I see is not good, I have to do the best I can to change things now, so my patients have the best possible chance.

As I spoke to Bill, I was slightly heartened. Despite his problems, he wasn’t in as bad a shape as I’d first envisaged, and I predicted that with a careful, good-working, regional anaesthetic technique, I may well be able to guide him through his operation.

I set about explaining to Bill and his daughter what I was planning to do and what he should expect. It took a while. It generally does. I was well aware that Bill was coming towards the end of his days and it only seemed fair to me to try and spend a little more time with him and his family. Interspersed in our chat about regional anaesthesia, we also chatted about how Bill would dearly love to go to see the local football team again (he’s still a season ticket holder) and how he couldn’t understand people who put the NHS down because his treatment had been fantastic.

Then Bill said something that gave me cause to pause. He said, “You know doctor, I’m an old man now, and I know you’re going to do your best for me, but what I want to say to is – don’t try too hard.”

At first I don’t understand what he’s driving at, I try and laugh it off and reassure him that, I was going to try very hard indeed – he deserved it after all, but Bill persisted. “I know that things can go wrong and what I mean is that if things do go wrong, you shouldn’t try too hard to put me right again.”

At this point his daughter interjected with, “What my father is trying to say is that he doesn’t want to be resuscitated.”

“Oh” is all I can say. “I’ll respect that.”

I suppose that I was caught a bit off guard because the thought of resuscitating Bill hadn’t really crossed my mind because I was determined that he would not get to a point where resuscitation needed to happen.

Bill interrupts my reflection. “Thank you doctor,” he says. “Please… just let what will be, be.”

As I left Bill and his daughter to prepare theatres, I pondered on Bill’s words. ‘Don’t try too hard,’ ‘don’t put me right,’ ‘let what will be, be.’ As these words rolled around my head, they sounded discordant. They sounded out of place, I got the feeling that they weren’t right, that they shouldn’t even be in my mind. This made me uncomfortable and I found myself initially subconsciously and then actively rejecting what Bill had said. I found the easiest thing for me to do what to ignore those words, put them out of my head and concentrate on finding the sterile vials of bupivicaine.

The trouble was, what Bill was asking goes against just about everything I’d learned. Not only that, it went against everything I was trying to achieve with this with this particular man’s anaesthetic. You see, with the elderly, unwell patients, I have to concentrate much MORE than I do with young, healthy patients. I have to try HARDER, be MORE precise because there’s so much less room for manoeuvre. I can’t “get away with it” if my technique is sloppy or if my regional blockade in not quite adequate.

I’ve realised that with young, healthy patients, you can “get away” with giving a pretty shoddy anaesthetic because they’ll compensate. Anaesthetising 30-year-olds is “easy.” You could train just about anyone to do it in a few months, indeed non-doctors are currently being trained to do just this. Giving a 94-yearold with multiple, serious medical problems an anaesthetic is a different prospect altogether. It’s not “easy” at all. It’s bloody difficult and if you get it wrong, they die.

So I’m sorry Bill, there’s no chance of me “not trying too hard,” I’m going to try as hard as I can because, as I said to you, you deserve it.

A lot has been written about us doctors trying to understand and empathise with our patients but it should be remembered that the “doctor-patient relationship” is exactly that. It’s a relationship, it’s a two-way process and I sometimes think that the other aspect of the relationship, that is the patient trying to understand their doctor, gets completely ignored.

At the end of the day, if I don’t give a good anaesthetic and Bill ends up dead, then I’ll feel responsible. I’ll feel guilty. I’ll go home and think to myself “that lovely man who made me laugh will never ever get to go the football again. His daughter will have to arrange his funeral and bury her father and it’s all my fault. Why the fuck didn’t I try harder? There was something I could have done, but I was too slack to do it, and now he’s dead it’s all my fault. He should be having rehab now and looking forward to catching the end of the season, instead, he’s lying cold and lifeless in the mortuary fridge and I could have done something to prevent this and I didn’t.”

I know that this is how I feel because I know myself. I’m only in my twenties and if I didn’t try hard enough and Bill died, then his memory will haunt me for years. I don’t want this so, Bill, this is partly the reason why I’m going to ignore what you said and I’m going to try as hard as I can.

But also:I'm not a medic, I don't know what I'm talking about, really, but cetainly from the point of this layperson there's a gap you could put a bus through between trying your best for Bill in terms of getting what you do, and how you do it, as close to just right as you possibly can and the sort of resucitation with jumping on chests and big electric pads that Bill may well be trying to avoid.

I don't think you need to feel you're not doing what Bill hopes you'll do in getting him safely through his surgery.

His request to you seems to have been concerned specifically with resuscitation in the event of it being required. This does not really have any bearing upon the efforts that you will make to give a good anaesthetic - which I'm sure he would be keen for you to do.

Clearly, if you made a mistake with the anaesthetic and he died as a result this would be a major problem. However, if you were to do your best with the anaesthetic and for whatever reason things went wrong with the operation to the stage that he did need resuscitation, you would at that point need to consider his views.

In a way, I'm a little concerned by your statement that "I'm going to ignore what you said and I'm going to try as hard as I can". Whilst this might apply to the anaethetic etc, would this also apply to resuscitation if needed? If something had gone wrong in the operation, and he needed resus, would you have allowed it to proceed or would you have stepped in to stop it, on the basis that you knew that this was not what he wanted? You might view this as not doing your best, but on the other hand this was his decision. This is a man who is clearly in full possession of his faculties who does not wish to be subjected to the trauma of CPR etc.

Following the recent Mental Capacity Act we are now required buy law to take into account 'advance statements' such as these. If attempts had been been made to resuscitate him and his daughter had later complained to the hospital that his wishes had been ignored, the hospital might find itself in trouble.

I guess what I am saying is that doctors often struggle when patients want something different than what we believe is best for them. However, it is their life and not ours, and we need to respect that. Most of the time, the law requires that we should allow people to choose what they want to happen to them, whether we agree with it or not.

There are exceptions - most of my patients fundamentally disagree with their treatment, and I am legally empowered to enforce it. But this does not apply to the vast majority of treatment given, and by and large we need to think very carefully before doing something which conflicts with the patient's ideas of what should happen to them.

I went see Bill during my lunch break yesterday and he’s recovering well from his surgery. There were no dramas or crises during the anaesthetic or surgery, but Bill’s now 2-3 days post-op and this is the danger time because this is when things tend to go wrong. I really hope he pulls through.

To respond to a couple of specific points above, Anonymous & DrJDR, thinking back again to my chat with Bill, I think he and I had different ideas of what “trying hard” means. (I think) he thought it meant CPR whereas I thought it means giving a good anaesthetic so that, hopefully, CPR doesn’t need to happen in the first place and this is why I had a bit of trouble getting my head around his words.

DrJDR, you raise some good points about advance statements. Bill’s daughter said that Bill didn’t want resuscitating, but what does resuscitation mean when you apply it to anaesthesia? It’s one thing if Bill was found dead on the ward, but in theatres, he will be constantly monitored and watched so that signs of deterioration can be picked up and acted upon long before he has a cardiac arrest. Is acting on these signs “resuscitation?” I wasn’t lying when I said that I’d respect his wishes, but if you think about it, it’s quite hard to decide where the line is. In the theatre environment, what is “resuscitation” and what is “a basic level of care?” I’ll give you some examples to highlight this dilemma and say how far I would have gone with Bill.

If he became overly sedated and obstructed his airway:Would I do some airway manoeuvres (chin-lift, jaw-thrust) to unobstruct it? Yes. Is this resuscitation?Would I give oxygen? Yes. Is this resuscitation?

If he started to become hypoxic and his oxygen saturation started to fall:Would I ventilate him with a bag and mask? Yes. Is this resuscitation?Would I intubate him and convert to general anaesthesia? Yes. Is this resuscitation?

If his blood pressure started to fall dangerously low:Would I give him intravenous fluids? Yes. Is this resuscitation?Would I give him inotropes? Yes. Is this resuscitation?Which one?Metaraminol? Yes. Is this resuscitation?Ephedrine? Yes. Is this resuscitation?Atropine? Yes. Is this resuscitation?Adrenaline? Yes. Is this resuscitation?

If these things didn’t work, would I start chest compressions? No.

Basically, rightly or wrongly, I’ve taken his “I don’t want to be resuscitated” statement to mean “I don’t want chest compressions.” I think that if I’d not done the things I’ve listed above, I would have been negligent and not providing the best care I could. In a way, you could say that anaesthetists are continually resuscitating their patients as they have their surgery, so a patient coming down for surgery who “doesn’t want to be resuscitated” poses a particular dilemma for us.

As above, this is an interesting take on the situation and one I hadn't really thought of.

Typical psychiatrist, eh?

In our hospitals, anything more challenging that a mild chest infection or an ingrowing toenail is enough to require 'the hospital' and although we are trying to improve physical care of psychiatric inpatients there is only so much you can do...

Just found your blog and I think it's brilliant. I'm a wannabe anaesthetist 5th yr medical student with finals looming, and reading your entries gave me a much needed boost of motivation. You've also helped me focus on why I'm actually putting myself through all this shit; to be a good doctor, even a good anaesthetist, one day soon. Reading your blog counts as revision, right? :)

HI - you are quite right about the difference and that these advance decisons are not as black and white as people think. My late husband in his 80s, when in the end stage of heart failure, told our GP no resuscitation nor anibiotics if he got pneumonia I then asked him what if he got pneumonia next week as a result of gettting a grandchild's cold and he said to treat it. He didnt mean as early as this. In the end though I was able to allow him to die of pneumonia when he was too ill to make the decision because I was clear then about what he wanted when. So the moral is that good discussion and clarification is needed. mary P

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